Landon Brown

3D Breast/Chest Wall Lab

11/17/2023
3D Breast/Chest Wall Lab
This plan was my first breast plan that was not a simple 2 field tangent plan. I initially
was overwhelmed with all of the different treatment volumes and the overall process of treating
this patient, but after getting some help and watching a few dosimetrists do similar plans, I
started to connect some dots. I ended up learning a lot from this lab and now have a much better
understanding of how to treat breast patients.
Isocenter/Field Matching
The first step to treat this patient was to choose the correct isocenter. The correct isocenter is
crucial to creating an ideal breast plan. I was given multiple treatment volumes including the
chest wall, supraclav, internal mammary, and axillary nodes. Given these volumes I chose to go
with the monoisocentric technique, because it is beneficial to both the patient and the therapists
by shortening treatment time and preventing therapists from having to deal with table kicks or
manual match lines. This technique involves placing isocenter at the superior border of the
tangent field and the inferior border of the supraclav field and using a half beam block at
isocenter. I first looked in the coronal view to find the widest part of the patient's chest. I then
adjusted my beam angle to create a medial tangent field that included the least amount of lung
while also including the chest wall, inferior supraclav, inferior axillary, and IM node volumes. I
had to include the IM node volumes in my tangent fields due to their depth being over 4 cm in
some areas. My clinic site does not like to treat IM nodes deeper than 2.8 cm with electrons. The
only other technique options for these IM nodes would be a rapid arc plan or wide tangents,
which is what I chose to go with. Since the IM nodes were so deep, I had to open my tangents a
bit wider than I would usually like to and it caused my beam to catch more lung than I usually
do. On most tangent fields I try to not include any more than 2 cm of lung. Once I found a beam
angle I liked at 305 degrees, I opposed the field to ensure I liked how the lateral field looked and
made sure my isocenter was placed medially between these fields. This provided me with my X
and Y coordinates for isocenter. To get my Z coordinate I shifted my isocenter superiorly
approximately 2 cm below the humeral head. As seen in figure 1 below, this isocenter location
allows the therapist to treat the tangents as well as the supraclav fields without having to shift the
patient and use match lines since they are abutting.
Figure 1. Coronal view of isocenter (yellow circle).
Planning Process
I started off trying to get a good tangent plan before moving on to the supraclav field. Now that I
have the correct beam angles for my tangent fields, I shaped the MLCs to block the most lung I
could without hurting my coverage while having approximately a 1 cm border superior and
inferior of the PTV and 2 cm of flash past the patient’s chest wall. I initially had my MLCs
abutting my chest wall and IM nodes volumes, however I quickly found that made my lung and
heart dose too high. I had to adjust from there and cover some of my chest wall PTV towards the
inferior part of the PTV as seen below in figure 2.
Figure 2. BEV of medial tangent field with the chest wall PTV (red) and IM node PTV (orange).
After a few attempts I found that this combination of PTV blocked versus lung/heart blocked
worked out well for meeting my lung and heart constraints and still getting good PTV coverage.
I opposed the beam and made slight adjustments to the MLCs for the lateral tangent side.
The next step was to decide what energy would work best. It is important to choose the
correct beam energy that allows you to get the proper coverage. I initially wanted to go with 18x
energy to help keep my plan cool, but this higher energy makes it difficult to get good dose
coverage near the skin surface like you typically see with a 6x energy. I was able to utilize both
6x and 18x beams to take advantage and combine the best qualities of each energy. The 6x
energy was the primary energy used for both my medial and lateral tangents. I liked my dose
coverage, but my plan was too hot at 126%. I then added an additional 18x beam for both the
medial and lateral tangents to help cool it down to 118.9%. The 6x medial field was weighted at
30%, the 6x tangent field was 23.2%, the 18x medial and lateral fields were each weighted at
23.4%. I then created field in fields on my 6x beams to get my plan down to 115.8%. At this
point I was happy with my coverage and my overall plan hotness was only 115.8% so I decided
to move on to my supraclav fields.
To treat the remaining supraclav and axillary volumes I had to create a new plan while keeping
my same isocenter. I set my gantry angle to 345 degrees in order to avoid the spinal cord and
avoid a lot of the esophagus. I created a field from the anterior side blocking out the humeral
head and as much of the esophagus and spinal cord as I could while still achieving good
coverage. Also, to visualize my treatment volumes and see what coverage it was getting, I
created a PTV opti structure for my supraclav and axillary volumes. I combined these volumes
and removed the parts of the volume that the tangent fields treated so that only the untreated
portions of these volumes remained. Figure 3 shows a good example of this.

Figure 3. Anterior field showing MLC placement. The spinal cord (yellow) is completely
blocked and part of the esophagus (orange) is also blocked. My supraclav and axillary nodes
PTV opti (pink) was created to help me see my coverage.
Once satisfied with my anterior field, I created a posterior field with similar blocking and made
slight MLC adjustments on it. I went back and forth on whether to place this beam at 180
degrees or make truly opposed at 165 degrees. I went with the 165 degree angle due to the spinal
cord and esophagus being further out of the field and I didn’t notice much difference in coverage
otherwise.
I started with 6x energy for the anterior field due to how shallow the target was and wanting to
achieve good coverage near the skin and I used 18x energy for the posterior field since I was
trying to get dose further through the body. My coverage was not too bad from this, but my plan
was very hot at 130%. I then adjusted my anterior field to an 18x energy and this helped cool my
plan down to 119.5% while still getting good coverage on the anterior portion of my PTV.
 Coverage
The dose coverage requirements for this lab were a little different than what the doctors at my
clinic site usually prefer. At my clinic site they commonly want 95% of the dose to cover 95%
percent of the volume for all the fields other than IM nodes which can go as low as 90% of the
dose covering 90% of the volume. There were two minimal coverage requirements for each
volume on this plan. The chest wall, supraclav, and axillary nodes were required to get a
minimum of 45 Gy covering 95% of the volume and 90% of the volume must be covered by 45
Gy. For the IM nodal volume, a minimum of 40 Gy must cover 95% of the volume and 80% of
the volume must be covered by 40 Gy.
My chest wall PTV had great coverage with 50.3 Gy covering 95% of the volume and 98.4% of
the volume being covered by 45 Gy. My IM nodes PTV was not as great but did meet the
requirements with 44.3 Gy covering 95% of the volume and 99.5% of the volume being covered
by 40 Gy. Figures 4, 5, and 6 show the isodose lines with the bold red line being a structure I
created that involved combining all my PTVs into one structure.

Figure 4. Axial view of isodose lines.

Figure 5. Frontal view of isodose lines.
Figure 6. Sagittal view of isodose lines.
Coverage for my supraclav and axillary volumes were a bit more challenging for me. I had to do
a lot more manipulating of my normalization which I will discuss in the next section. My axillary
coverage ended up being good with 51 Gy covering 95% of the volume and 100% of the volume
covered by 45 Gy. My supraclav coverage was not as good, but still met requirements with 49
Gy covering 95% of the volume and 97.8% of the volume covered by 45 Gy. Figures 7, 8, and 9
show the isodose lines with the bold red line being a structure I created that involved combining
all my PTVs into one structure.
Figure 7. Axial view of isodose lines.
Figure 8. Frontal view of isodose lines.
Figure 9. Sagittal view of isodose lines.
My hot spot was 6165 cGy which was well under the 6400 cGy the plan allowed for.
Unfortunately, it was not found in the PTV, but it was slightly anterior of the axillary PTV. For
IMRT plans it is important to have your hot spot in the PTV, but since this is a conformal plan, it
is acceptable for it to be outside of the plan. Figure 10 shows the location of the hot spot in the
axial view.
Figure 10. Axial view of the hot spot
There were a few cold spots that were not covered by 50 Gy. The posterior, medial portion of the
supraclav volume did remain cold with only 1833 cGy of coverage as seen in figure 11.
Figure 11. Axial view of cold spot in supraclav volume.
The other cold spots were seen towards the medial, inferior portion of the chest wall PTV and the
superior portion of the IM volume. The IM volume was covered with 3768 cGy of dose at its
coolest spot while the chest wall PTV has a spot that is only getting 1182 cGy. All of these cool
spots are found on the periphery of the PTV and can be expected on plans like these. I spoke
with a doctor and she said they rarely focus on the minimum dose location if the overall tumor
coverage is good and these cold spots are not in the middle of the PTV.
Normalization
For many of my plans, I utilize the option of choosing what percent of dose will cover what
percent of the target volume. For a typical breast plan I would have usually done 95% of the dose
covering 95% of the volume, however for this plan I chose to use the plan normalization value
for the tangent fields and a calc point for my supraclav and axillary fields. I chose these methods
due to the constraints and coverage requirements I had. For the tangent fields I initially started
off with 95% of my dose covering 95% of my volume. I was happy with my coverage for my
tangents, but as I moved on further into my plan, I noticed that I was lacking coverage for my
axillary and supraclav volumes and was able to bump my coverage up to help fix that issue. I
ended up increasing my coverage by lowering my plan normalization value to 78.13%. This
essentially increased my chest wall coverage so that 96.2% of my volume was receiving 95% of
the dose and more importantly my axillary and supraclav volumes increased as well. It also
increased my overall plan hotness, but I was well under the required constraints of 64 Gy so I felt
it was necessary to normalize this way.
I had issues getting good coverage on my supraclav field and eventually chose to use a
calc point. This was my first time using a calc point and it really helped me get the coverage I
wanted without being extremely hot. When I normalized the plan with 95% of the dose going to
95% of the volume this caused my plan to be near 130% with 100% coverage going through all
of the left lung. Once I inserted a calc point and adjusted its location I achieved the good
coverage I was looking for while my plan was only at 119.5%. I tried multiple different locations
but eventually settled on the calc point location towards the center of the patient’s body near the
inferior portion of the field and normalized so that 100% of the dose goes to that calc point.
Figure 12 shows you the location of my calc point in the axial view.

Figure 12. Calc point location labeled SC CALC.

Constraints
As far as the metrics go for the Pro Know’s score card I was able to meet all the constraints.
There were 18 metrics given and I was able to get the “ideal” score on 7 of those, 7 of them I
achieved the “good” score, and I got the “acceptable” score on 4 of them. (My final scorecard
can be seen at the end of this assignment labeled as figure 18.) The constraint I struggled most
with was the heart. I initially did not have much of the heart covered by MLCs to allow my PTV
to be fully exposed to the beam, but I quickly found that I would not be able to meet the
constraint like that. I was unaware that you were able to cover the PTV in order to meet
constraints. After getting help from another dosimetrist, I closed the MLCs a bit more towards
the inferior portion of the chest wall PTV. This did decrease my coverage in that area, but
drastically improved my heart dose mean which felt like a fair tradeoff. This can be seen below
in figure 13.

Figure 13. BEV of medial tangent beam with target volumes and heart structure on.
I found my biggest mistake with this plan after I completed it, and I began to work on this write
up. My LAD mean dose was 2400 cGy. At my clinic site, our doctors prefer the LAD mean dose
to be around 700 cGy. It makes sense why the mean dose was so high since close to half of the
LAD is not blocked out on my tangent fields. I have not planned a left sided breast in clinic up to
this point so blocking it did not cross my mind. I now know from other plans I have done since
this one that it is crucial to block your LAD even if that means sacrificing PTV coverage. If I had
blocked more of the LAD, my coverage would have suffered in that location, but I believe I
would have been able to get my LAD mean dose down closer to 700 cGy. I did find a study
testing the correlation between certain LAD doses and major cardiac events. They found that
LAD doses over V15 Gy greater than or equal to 10% and a dose mean of 7 Gy increased
patients’ chances of a 2-year all-cause mortality estimate by nearly 10%.1 This estimate increases
if the patient has pre-existing heart issues. Keeping the LAD dose as low as possible is a very
important area to focus on during treatment planning. It is important to get proper coverage to
the target volumes for the patient, but it is equally as important to minimize harm to patients as
well.
Plan Sum Coverage
Below in figures 14, 15, and 16 show the isodose lines from my plan sum at isocenter in the
axial, frontal, and sagittal views.

Figure 14. Axial view of isodose lines.

Figure 15. Frontal view of isodose lines.
Figure 16. Sagittal view of isodose lines.
DVH
Below in figure 17 you can see my DVH from my plan sum of all my PTVs, including
my PTV total I created, along with important OAR structures. I checked my OAR structures
using Timmerman and found that all the structure’s doses were acceptable, except for the LAD
which I spoke about in the previous section.
Figure 17. DVH of my target volumes and important OARs.

ProKnow Scorecard
Figure 18. My ProKnow scorecard.

References
1. Atkins KM, Chaunzwa TL, Lamba N, et al. Association of Left Anterior Descending
Coronary Artery Radiation Dose With Major Adverse Cardiac Events and Mortality in Patients
With Non–Small Cell Lung Cancer. JAMAOncol. 2021;7(2):206-219.
doi:10.1001/jamaoncol.2020.6332